· AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS . RUC RECOMMENDATIONS FOR CPT 2021 . February 2020...

AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS RUC RECOMMENDATIONS FOR CPT 2021

February 2020 Meeting

TABLE OF CONTENTS

Cover Letter _ TAB Table of Contents .................................................................................................................................. 01 RUC Recommendations Cover Letter .................................................................................................. 02 Introductory Materials _ TAB Resource Materials ................................................................................................................................ 03 New/Revised CPT Codes CPT 2021 _TAB Tissue Expander Other Than Breast (11960).………………………………………………………. .. 04 Breast Implant/Expander Placement (11970, 19325, 19340, 19342, 19357) ………………………....05 Breast Implant/Expander Removal (11971, 19328, 19330)……………………………………………06 Secondary Breast Mound Procedure (19370, 19371, 19380)…………………………….…………… 07 Breast Lift/Reduction (19316, 19318)……………………………………………….…………………08 Femur Lengthening Device Procedures (27465, 27466, 27468, 27X00)………………….…………...09 Tibia Lengthening Device Procedures (27715, 27X16)…………………………………….………….10 Shoulder Debridement (29822, 29823)..…………………………………………………….…………11 Absorbable Nasal Implant Repair (30XX0)……………………………………………………………12 Atrial Septostomy (33XX0, 33XX1, 33XX2)..………………………………………………………...13 Computer-Aided Mapping of Cervix Uteri (57XX0)………………………………………….……….14 Dilation of Eustachian Tube (697XX, 697X1)……………………………………………….………...15 Medical Physics Dose Evaluation (PE Only) (7615X)……………………………………….………...16 Ophthalmic Ultrasound Anterior Segment (76510, 76511, 76512, 76513, 76514)..………….………..17 External Extended ECG Monitoring (93224, 93225, 93226, 93227, 93XX0, 93XX1,…………….…..18 93XX2, 93XX3, 93XX4, 93XX5, 93XX6, 93XX7)

Prolonged Services (99358, 99359)…………………………………………….………………………19 Chronic Care Management Services (99490, 994XX, 99491, 99487, 99489)…………………………20 CMS Request/Relativity Assessment Identified Codes_____________________ TAB Fine Needle Aspiration (10004, 10005, 10006, 10007, 10008, 10009, 10010, 10011,…….…….…….21 10012, 10021) Modified Radical Mastectomy (19307).………………………………………………………………..22

Closed Treatment of Vertebral Body Fracture(s) (22310). …………………………………………….23 Repair Recurrent Hernia (49565).………………………………………………………….…………...24 Percutaneous Nephrostolithotomy (50080, 50081).………………………………………….………....25 Colpopexy (57282, 57283) ................................................................................................................... ...26 Laparoscopic Colpopexy (57425).……………………………………………………………………. ..27 X-Ray of Eye (70030)…………… ....................................................................................................... ...28 Venography (75820, 75822).……………………………………………………………….…….……..29 . 3D Rendering with Interpretation and Report (76377).….………………………………....…………...30 Radiation Treatment Delivery (PE Only) (77401).…………….……………………………………......31 Liver Elastography (91200).…………………………………………………………………………..... 32 Insertion/ Removal of Implantable Interstitial Glucose Sensor System (0446T, 0447T, 0448T)..………33 Visit Complexity EM Add-On (GPC1X) ............................................................................................. …34

February 6, 2020 Seema Verma, MPH Administrator Center for Medicare Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD 21244-1850 Subject: RUC Recommendations Dear Administrator Verma: The American Medical Association (AMA)/Specialty Society RVS Update Committee (RUC) submits the enclosed recommendations for work relative values and direct practice expense inputs to the Centers for Medicare and Medicaid Services (CMS). These recommendations relate to new and revised codes for CPT 2021, as well as to existing services identified by the RUC’s Relativity Assessment Workgroup and CMS. Enclosed are the RUC recommendations for all the CPT codes reviewed at the January 15-18, 2020 RUC meeting. CPT 2021 New and Revised Codes – January 2020 RUC Submission The enclosed binder contains RUC recommendations, including those for new and revised CPT codes. The RUC considered 54 new/revised/related family CPT codes at the January 2020 meeting. The RUC recommends that 8 codes be referred to the CPT Editorial Panel. The RUC submits work value and/or practice expense inputs for 46 new/revised/related family CPT codes from the January 2020 meeting. CPT 2021 New and Revised Codes – Entire CPT 2021 Cycle The total number of coding changes for the entire CPT 2021 cycle is 190, including 78 additions, 60 revisions, and 35 deletions. In addition, 17 new codes were identified as part of the family for review in relationship to the new/revised codes. Of the 155 new/revised/related family CPT codes, 52 services are not payable on the RBRVS or do not require physician work (eg, laboratory services and vaccines), and accordingly, the RUC does not submit any information on these codes. The RUC refers 8 codes to the CPT Editorial Panel.

The RUC submits work value and/or practice expense inputs for 95 new/revised/related family CPT codes for the 2021 Medicare Physician Payment Schedule. Existing Services Identified by RUC and CMS for Review In addition to the new/revised CPT code submission, the RUC submits recommendations for 20 services identified by the RUC or CMS as potentially misvalued and reviewed at the January 2020 RUC meeting. The RUC recommends work relative values for 11 codes, direct practice expense inputs only for one code, referral to CPT for 7 codes and no specific recommendation on the valuation of one code (GPC1X).

Seema Verma, MPH February 6, 2020 Page 2

The RUC recommendations are in addition to the 35 recommendations for existing services submitted to CMS following the RUC’s April and October 2019 meetings. RUC Progress in Identifying and Reviewing Potentially Misvalued Codes Since 2006, the RUC has identified 2,545 potentially misvalued services through objective screening criteria and has completed review of 2,456 of these services. The RUC has recommended that over half of the services identified be decreased or deleted (Figure 1). The RUC has worked vigorously over the past several years to identify and address mis-valuations in the RBRVS through provision of revised physician time data and resource recommendations to CMS. The RUC looks forward to working with CMS on a concerted effort to address potentially misvalued services. A detailed report of the RUC’s progress is appended to this letter (attachment 01). Figure 1: AMA/Specialty Society RVS Update Committee (RUC) Potentially Misvalued Services Project

CMS to Review Unexplained Claims The RUC identified Psychiatric Collaborative Care Management Services (CPT codes 99492, 99493 and 99494) via the work neutrality (CPT 2018) screen. These services showed a 468% increase in work RVUs for 2018. Therefore, the specialty societies submitted an action plan for the Relativity Assessment Workgroup to discuss. In reviewing the utilization data for these services, it appears one independent clinic is performing most of these services in the pediatric population. The RUC recommends that CMS investigate the reporting of services by this specific independent clinic. Please see attachment 02 which indicates all the 2018 Medicare claims reported by one specific independent clinic. Request for CMS to Delete G-Codes The RUC identified International Normalized Ratio (INR) Monitoring (CPT codes 93792 and 93793) via the work neutrality (CPT 2018) screen. CMS created G0248 Demonstration, prior to initiation of home inr monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria, under the direction of a physician; includes:

4%

18%

40%

12%

26%Codes under Review, 89, 4%

Deleted, 463, 18%

Decreased, 1,025, 40%

Increased, 306, 12%

Reaffirmed, 662, 26%


face-to-face demonstration of use and care of the inr monitor, obtaining at least one blood sample, provision of instructions for reporting home inr test results, and documentation of patient's ability to perform testing and report results, G0249 Provision of test materials and equipment for home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests and G0250 Physician review, interpretation, and patient management of home inr testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests to describe these services before 93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results and 93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed were developed. These services showed a 314% increase in work RVUs for 2018. The Relativity Assessment Workgroup noted that 93792 and 93793 were new codes and an increase was expected as these services were not specifically described before. The Relativity Assessment Workgroup also noted that the RUC recommended that CMS delete G0248, G0249 and G0250 at that time. CMS did not delete these G codes for CY2018. The RUC continues to recommend that CMS delete G0248, G0249 and G0250. Practice Expense Subcommittee The attached materials include direct expense input (medical staff, supplies and equipment) recommendations for each code reviewed. As a reminder, cost estimates for proposed new clinical staff types, medical supplies and medical equipment (not listed as part of the CMS labor, supply, and equipment lists) are based on provided source(s), such as paid invoices and may not reflect the wholesale prices, quantity, cash discounts, prices for used equipment or any other factors that may alter the cost estimates. The RUC shares this information with CMS without making specific recommendations on the pricing. Immunization Administration The RUC requests that CMS correct the practice expense RVUs for immunization administration to be resource-based. We have found that although CMS has published the RUC recommended direct practice expense inputs for immunization administration codes 90460, 90471 and 90473, the published PE RVU of 0.22 in the nonfacility setting is not accurate for those direct practice expense inputs. Rather than implementing the direct practice expense input RUC recommendations made in 2009 to develop the PE RVUs, CMS crosswalked or more accurate for PE RVUs, hardcoded, the PE RVU for 90460, 90471 and 90473 from CPT code 90471, which is hardcoded from CPT code 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (formerly CPT code 90772 and then 90782). The direct practice expense inputs used to develop the PE RVU for CPT code 96372 results in a PE RVU of 0.22 which greatly underestimates the resources needed to provide immunization services in the office setting. This is also true of immunization administration add-on codes 90461, 90472 and 90474. These three codes have a published PE RVU of 0.20 in the nonfacility setting which is not accurate for the published direct practice expense inputs for those codes. Although these three codes are clearly hardcoded to the PE RVUs of another code it is difficult to determine exactly which code the codes are hardcoded to. For all 6 codes the result is approximately 60 percent reduction in


PE RVUs resulting in payment substantially lower than current Centers for Disease Control and Prevention (CDC) regional maximum charges. Historically, when crosswalks are utilized it is only for work values, not PE relative value units. The use of a crosswalk for practice expense RVUs means that the codes are not resource based because they do not account for the appropriate clinical staff time, supplies and equipment to furnish the services. Appropriate payment for immunization administration is critical in maintaining high immunization rates in the United States as well as having the capacity to respond quickly to vaccine preventable disease outbreaks. Finally, it should be noted that CMS has already validated the RUC-recommended values for CPT code 90460. CMS used the RUC-recommended values for CPT code 90460 to value the fast-tracked H1N1 immunization administration code (90470) for 2010—as both codes were reviewed during the same RUC meeting (October 2009). Accordingly, CMS should use the RUC recommended resource-based direct practice inputs to develop the PE RVU for CPT codes 90460, 90461, 90471, 90472, 90473 and 90474. The RUC recommendations for all six CPT codes are attached to this letter. (See attachments 03a and 03b). Utilization Assumption Corrections

Dilation of Urinary Tract (CPT codes 50436, 50437) In January 2015, the RUC referred CPT code 50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous, which was identified as part of the family of other genitourinary catheter procedures that were being reviewed at the time, to the CPT Editorial Panel to clear up confusion with overlap in physician work with 50432 Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation. In September 2017, the CPT Editorial Panel deleted CPT code 50395 nephrostomy tract code and created two new codes (50436 and 50437) to report (1) dilation of an existing tract, and (2) establishment of new percutaneous access to the collecting system for an endourologic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy), all associated radiological supervision and interpretation, as well as post procedure tube placement when performed. Imaging was also bundled into the new codes included in those codes. In February 2018, the RUC submitted recommendations for CPT Codes 50436 and 50437 along with codes 50432, 50433 and 74485. In the CY2019 MPFS Final Rule, CMS rejected the RUC recommendations for 50436 and 50437 and instead opted to assign both services much lower work values:

Code Long Descriptor

February 2018 RUC

Recommended Work RVU

CY2019 CMS

Finalized Work RVU

50436 Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, as well as post procedure tube placement, when performed;

3.37 2.78

50437 Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, as well as post procedure tube placement, when performed; including new access into the renal collecting system

5.44 4.85


In November 2018, AMA RUC staff discovered that CMS erroneously double-counted the utilization for new codes that had image guidance bundled, in both this Dilation of Urinary Tract code family and in the Fine Needle Aspiration code family causing the Agency to incorrectly believe that the RUC was recommending large increases in physician work for both families of services, when in fact the RUC was recommending a work savings for each family. This is made clear by reviewing the large year over year volume increases for all of the new codes in the “CY 2017 Utilization Data Crosswalk to CY 2019” CMS CY2019 Final Rule spreadsheet, where the Agency had 5,528 utilization for new code 50436 and 913 utilization for new code 50437. Whereas, these services were collectively replacing deleted code 50395, which only had a utilization of 3,022. CMS had accidentally also included roughly 2,500 utilization from the bundled imaging code, 74485 Dilation of ureter(s) or urethra, radiological supervision and interpretation, resulting in a double counting of the procedure. This error made it appear like the RUC was recommending a work RVU pool that was roughly twice as high as was the case. The RUC recommendations for codes 50436 and 50437 are more appropriate than the current CMS values as the current CMS values create rank order anomalies. The RUC recommendations are strongly supported by the RUC recommendations for CY2019, which the RUC is resubmitting to the Agency along with the multispecialty letter concerning this issue submitted to CMS in January 2019 (attachments 04a and 04b). The RUC recommends for CMS to reconsider their CY2019 Medicare Physician Fee Schedule Final Rule decision for code 50436 and 50437 considering this new information. Enclosed Recommendations and Supporting Materials: Included in these binders and on the enclosed USB drive are:

• RUC Recommendation Status Report for New and Revised Codes

• RUC Recommendation Status Report for 2,545 services identified to date by the Relativity Assessment Workgroup and CMS as potentially misvalued. In addition, a spreadsheet containing the codes specific to this submission is included.

• RUC Referrals to the CPT Editorial Panel – both for CPT nomenclature revisions and CPT

Assistant articles.

• Physician Time File: A list of the physician time data for each of the CPT codes reviewed at the January 2020 RUC meeting.

• Pre-Service and Post-Service Time Packages Definitions: The RUC developed physician pre-

service and post-service time packages which have been incorporated into these recommendations. The intent of these packages is to streamline the RUC review process as well as create standard pre-service and post-service time data for all codes reviewed by the RUC.

• PLI Crosswalk Table: The RUC has committed to selecting appropriate professional liability

insurance crosswalks for new and revised codes and existing codes under review. We have provided a PLI Crosswalk Table listing the reviewed code and its crosswalk code for easy reference. We hope that the provision of this table will assist CMS in reviewing and implementing the RUC recommendations.


• BETOS Assignment Table: The RUC, for each meeting, provides CMS with suggested BETOS classification assignments for new/revised codes. Furthermore, if an existing service is reviewed and the specialty believes the current assignment is incorrect, this table will reflect the desired change.

• Utilization Crosswalk Table: A table estimating the flow of claims data from existing codes to the

new/revised codes. This information is used to project the work relative value savings to be included in the 2021 conversion factor increase.

• New Technology List and Flow Chart: In April 2006, the RUC adopted a process to identify and

review codes that represent new technology or services that have the potential to change in value. To date, the RUC has identified 676 of these procedures through the review of new CPT codes. A table of these codes identified as new technology services and the date of review is enclosed, as well as a flow chart providing a detailed description of the process to be utilized to review these services.

• RUC Recommendations on Modifications to Visits in the Global Period – February 2020. We appreciate your consideration of these RUC recommendations. If you have any questions regarding the attached materials, please contact Sherry Smith at (312) 464-5604. Sincerely,

Peter K. Smith, MD Enclosures cc: RUC Participants Edith Hambrick, MD Gift Tee Karen Nakano, MD Marge Watchorn Michael Soracoe

The RUC Relativity Assessment Workgroup Progress Report In 2006, the AMA/Specialty Society RVS Update Committee (RUC) established the Five-Year Identification Workgroup (now referred to as the Relativity Assessment Workgroup) to identify potentially misvalued services using objective mechanisms for reevaluation prior to the next Five-Year Review. Since the inception of the Relativity Assessment Workgroup, the Workgroup and the Centers for Medicare and Medicaid Services (CMS) have identified more than 2,500 services through 20 different screening criteria for further review by the RUC. Additionally, the RUC charged the Workgroup with maintaining the “new technology” list of services that will be re-reviewed by the RUC as reporting and cost data become available. To provide Medicare with reliable data on how physician work has changed over time, the RUC, with more than 300 experts in medicine and research, are examining 2,545 potentially misvalued services accounting for $45 billion in Medicare spending. The update committee has recommended reductions and deletions to 1,488 services, redistributing $5 billion annually. Here are the outcomes for the committee’s review of 2,545 codes: Potentially Misvalued Services Project

Source: American Medical Association New Technology As the RUC identifies new technology services that should be re-reviewed, a list of these services is maintained and forwarded to CMS. Currently, codes are identified as new technology based on recommendations from the appropriate specialty society and consensus among RUC members at the time of the RUC review for these services. RUC members consider several factors to evaluate potential new technology services, including: recent FDA-approval, newness or novelty of the service, use of an existing service in a new or novel way, and migration of the service from a Category III to Category I CPT® code. The Relativity Assessment Workgroup maintains and develops all standards and procedures associated with the list, which currently contains 676 services. In September 2010, the re-review cycle began and since then the RUC has recommended 48 services to be re-examined. The remaining services

4%

18%

40%

12%

26%Codes under Review, 89, 4%

Deleted, 463, 18%

Decreased, 1,025, 40%

Increased, 306, 12%

Reaffirmed, 662, 26%

The RUC Relativity Assessment Workgroup Progress Report – February 2020 2

are rarely performed (i.e., less than 500 times per year in the Medicare population) and will not be further examined. The Workgroup will continue to review the remaining 214 services every October after three years of Medicare claims data is available for each service. Methodology Improvements The RUC implemented process improvements to methodology following its October 2013 meeting. The process improvements are designed to strengthen the RUC’s primary mission of providing the final RVS update recommendations to the Centers for Medicare and Medicaid Services. In the area of methodology, the RUC is continuously improving its processes to ensure that it is best utilizing reliable, extant data. At its most recent meeting, the RUC increased the minimum number of respondents required for each survey of commonly performed codes: • For services performed 1 million or more times per year in the Medicare population, at least 75

physicians must complete the survey. • For services performed from 100,000 to 999,999 times annually, at least 50 physicians will be required. Further strengthening its methodology, the RUC also announced that specialty societies will move to a centralized online survey process, which will be coordinated by the AMA and will utilize external expertise to ensure survey and reporting improvements. Site of Service Anomalies The Workgroup initiated its effort by reviewing services with anomalous sites of service when compared to Medicare utilization data. Specifically, these services are performed less than 50% of the time in the inpatient setting, yet include inpatient hospital Evaluation and Management services within their global period. The RUC identified 194 services through the site of service anomaly screen. The RUC required the specialties to resurvey 129 services to capture the appropriate physician work involved. These services were reviewed by the RUC between April 2008 and February 2011. CMS implemented 124 of these recommendations in the 2009, 2010 and 2011 Medicare Physician Payment Schedules. The RUC submitted another five recommendations as well as re-reviewed and submitted 44 recommendations to previously reviewed site of service identified codes to CMS for the 2012 Medicare Physician Payment Schedule. Of the remaining 65 services that were not re-surveyed, the RUC modified the discharge day management for 46 services, maintained three codes and removed two codes from the screen as the typical patient was not a Medicare beneficiary and would be an inpatient. The CPT® Editorial Panel deleted 14 codes. The RUC completed review of services under this initial screen. During this review, the RUC uncovered several services that are reported in the outpatient setting, yet, according to several expert panels and survey data from physicians who perform the procedure, the service, typically requires a hospital stay of greater than 23 hours. The RUC maintains that physician work that is typically performed, such as visits on the date of service and discharge work the following day, should be included within the overall valuation. Subsequent observation day visits and discharge day management service are appropriate proxies for this work. The RUC will reassess the data each year going forward to determine if any new site of service anomalies arise. In 2015, the RUC identified three services in which the Medicare data from 2011-2013 indicated it was performed less than 50% of the time in the inpatient setting, yet included inpatient hospital Evaluation and Management services within the global period. These services were referred to CPT and recommendations were submitted to CMS for the 2018 Medicare Physician Payment Schedule.


In 2016, the RUC identified one site of service anomaly CPT code and submitted the recommendation to CMS for the 2019 Medicare Physician Payment Schedule. In 2017, the RUC identified one site of service anomaly CPT code which was revised at the CPT Editorial Panel and the RUC submitted recommendations for the 2020 Medicare Physician Payment Schedule. In 2018, the RUC also performed a site-of-service anomaly screen based on the review of three years of data (2015, 2016 and 2017e) for services with utilization over 10,000 in which a service is typically performed in the inpatient hospital setting, yet only a half discharge day management (99238) is included. One service was identified via this screen and another identified for the outpatient site of service anomaly screen. The RUC submitted this recommendation for the 2021 Medicare Physician Payment Schedule. In 2019, the RUC lowered the threshold for site-of-service anomalies based on the review of three years of data (2016, 2017 and 2018e) for services with utilization over 5,000 in the outpatient setting more than 50% of the time but includes inpatient hospital Evaluation and Management services within the global period. The RUC identified nine services, expanding to 10 services to include the family of services. The RUC referred three codes to the CPT Editorial Panel for revision and submitted seven recommendations for the 2021 Medicare Physician Payment Schedule. High Volume Growth The Workgroup assembled a list of all services with a total Medicare utilization of 1,000 or more that have increased by at least 100% from 2004 through 2006. The query initially resulted in the identification of 81 services, but was expanded by 16 services to include the family of services, totaling 97 services. Specialty societies submitted comments to the Workgroup in April 2008 to provide rationales for the growth in reporting. Following this review, the RUC required the specialties to survey 35 services to capture the appropriate work effort and/or direct practice expense inputs. These services were reviewed by the RUC between February 2009 and April 2010. The RUC recommended removing 15 services from the screen as the volume growth did not impact the resources required to provide these services. The CPT® Editorial Panel deleted 34 codes. The RUC submitted 44 recommendations to CMS for services for the 2012-2017 Medicare Physician Payment Schedules and four recommendations for the CPT 2020 Medicare Physician Payment Schedule. The RUC completed review of services under this first iteration of the high growth screen. In April 2013, the RUC assembled a list of all services with a total Medicare utilization of 10,000 or more that have increased by at least 100% from 2006 through 2011. The query resulted in the identification of 40 services and expanded to 62 services to include the appropriate family of services. The RUC recommended removing three services from the screen as the volume growth did not impact the resources required to provide these services. The RUC recommended review of two services after an additional utilization data is collected. The CPT® Editorial Panel deleted ten codes and the RUC submitted recommendations for 47 services for the 2015-2019 Medicare Physician Payment Schedule. In October 2015, the RUC ran this screen again for services based on Medicare utilization of 10,000 or more that have increased by at least 100% from 2008 through 2013. The query resulted in the identification of 19 services and expanded to 31 services to include the appropriate family of services. The RUC recommended removing one service from the screen as the volume growth did not impact the resources required to provide these services. The RUC will review three services after an additional utilization data is collected. The CPT Editorial Panel deleted 12 codes and the RUC submitted recommendations for 15 services for the 2017-2020 Medicare Physician Payment Schedules.


In October 2016, the RUC ran this screen for its fourth iteration and the query resulted in the identification of 12 services, which was expanded to 46 services. The RUC recommended removing two services from the screen as the volume growth did not impact the resources required to provide these services. The CPT Editorial Panel deleted three services. The RUC submitted recommendations for 38 services for the 2019-2020 Medicare Physician Payment Schedules. The RUC referred one service to CPT for revision and will review one service for the 2022 Medicare Physician Payment Schedule. In October 2018, the RUC ran this query for its fifth iteration for services with 2017e Medicare utilization of 10,000 or more that has increased by at least 100% from 2012 through 2017. Eleven (11) codes were identified. The RUC recommended removing two services from the screen as the volume growth was appropriate. The CPT Editorial Panel deleted one code. The RUC referred one code to the CPT Editorial Panel for revision and submitted recommendations for seven services for the 2020-2021 Medicare Physician Payment Schedule. In October 2019, the RUC completed its sixth iteration of this screen for services with 2018e Medicare utilization of over 10,000 that have increased by at least 100% from 2013 through 2018. The RUC identified 12 services. The RUC removed three services from the screen as the volume growth did not impact the resources required to provide these services. The RUC referred four codes to the CPT Editorial Panel for revision and will review one code after additional utilization data is available. The RUC submitted recommendations for one service for the 2021 Medicare Physician Payment Schedule and will review the remaining three service for the 2022 Medicare Physician Payment Schedule. CMS Fastest Growing In 2008, CMS developed the Fastest Growing Screen to identify all services with growth of at least 10% per year over the course of three years from 2005-2007. Through this screen, CMS identified 114 fastest growing services and the RUC added 69 services to include the family of services, totaling 183. The RUC required the specialties to survey 72 services to capture the appropriate work effort and/or direct practice expense inputs. These services were reviewed by the RUC from February 2008 through April 2010 and submitted to CMS for the Medicare Physician Payment Schedule. The RUC recommended removing 27 services from the screen as the volume growth did not impact the resources required to provide the service. The CPT® Editorial Panel deleted 43 codes. The RUC submitted 41 recommendations to CMS for the 2012-2019 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. High IWPUT The Workgroup assembled a list of all services with a total Medicare utilization of 1,000 or more that have an intra-service work per unit of time (IWPUT) calculation greater than 0.14, indicating an outlier intensity. The query resulted in identification of 32 services. Specialty societies submitted comments to the Workgroup in April 2008 for these services. As a result of this screen, the RUC has reviewed and submitted recommendations to CMS for 28 codes, removing four services from the screen as the IWPUT was considered appropriate. The RUC completed review of services under this screen. Services Surveyed by One Specialty – Now Performed by a Different Specialty In October 2009, services that were originally surveyed by one specialty, but now performed predominantly by other specialties were identified and reviewed. The RUC identified 21 services by this screen, adding 19 services to address various families of codes. The majority of these services required clarification within CPT®. The CPT® Editorial Panel deleted 18 codes. The RUC submitted 22 recommendations for physician work and practice expense to CMS for the 2011-2014 Medicare Physician Payment Schedules. The RUC completed review of services under this screen.


In April 2013, the RUC queried the top two dominant specialties performing services based on Medicare utilization more than 1,000 and compared it to who originally surveyed the service. Two services were identified and the RUC recommended that one be removed from the screen since the specialty societies currently performing this service indicated that the service is appropriate and recommended that the other code be referred to CPT® to be revised. The RUC completed review of services under this screen. In October 2019, the RUC queried the top two dominant specialties performing services based on Medicare utilization more than 1,000 and compared it to who originally surveyed the service. Two services were identified, and the RUC referred them to the CPT Editorial Panel for revision and the CPT Assistant for education. Harvard Valued Utilization over 1 Million CMS requested that the RUC pay specific attention to Harvard valued codes that have a high utilization. The RUC identified nine Harvard valued services with high utilization (performed over 1 million times per year). The RUC also incorporated an additional 12 Harvard valued codes within the initial family of services identified. The CPT® Editorial Panel deleted one code. The RUC submitted 20 relative value work recommendations to CMS for the 2011 and 2012 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. Utilization over 100,000 The RUC continued to review Harvard valued codes with significant utilization. The Relativity Assessment Workgroup expanded the review of Harvard codes to those with utilization over 100,000 which totaled 38 services. The RUC expanded this screen by 101 codes to include the family of services, totaling 139 services. The CPT® Editorial Panel deleted 27 codes. The RUC submitted 112 recommendations to CMS for the 2011-2014 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. Utilization over 30,000 In April 2011, the RUC continued to identify Harvard valued codes with utilization over 30,000, based on 2009 Medicare claims data. The RUC determined that the specialty societies should survey the remaining 36 Harvard codes with utilization over 30,000 for September 2011. The RUC expanded the screen to include the family of services, totaling 65 services. The CPT® Editorial Panel deleted 12 codes. The RUC submitted recommendations for 53 services for the 2013-2014 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. In October 2015, the RUC reran this screen on Harvard valued services with 2014e Medicare utilization over 30,000. Seven services were identified and expanded to nine codes to include the family of services. The CPT Editorial Panel deleted two codes. The RUC submitted recommendations for 7 services for the 2018-2019 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. In October 2018, the RUC reran this screen on Harvard valued services with 2017e Medicare utilization over 30,000. One service was identified. The RUC submitted this recommendation for the 2021 Medicare Physician Payment Schedule. The RUC completed review of services under this screen. In October 2019, the RUC reran this screen on Harvard valued services with 2018e Medicare utilization over 30,000. Three services were identified. The RUC referred two services to the CPT Editorial Panel for revision and will review one service for the 2022 Medicare Physician Payment Schedule.


Medicare Allowed Charges >$10 million In June 2012, CMS identified 16 services that were Harvard valued with annual allowed charges (2011 data) > $10 million. The RUC expanded this screen to 33 services to include the proper family of services. The RUC removed two services from review as the allowed charges are approximately $1 million and did not meet the screen criteria. The CPT® Editorial Panel deleted one service. The RUC submitted recommendations for 30 services for the 2013-2017 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. CMS/Other Utilization over 500,000 In April 2011, the RUC identified 410 codes with a source of “CMS/Other.” CMS/Other codes are services which were not reviewed by the Harvard studies or the RUC and were either gap filled, most often via crosswalk by CMS or were part of a radiology fee schedule. “CMS/Other” source codes would not have been flagged in the Harvard only screens, therefore the RUC recommended that a list of all CMS/Other codes be developed and reviewed. The RUC established the threshold for CMS/Other source codes with Medicare utilization of 500,000 or more, which resulted in 19 codes. The RUC expanded this screen to 21 services to include the proper family of services. The CPT® Editorial Panel deleted three services. The RUC submitted recommendations for 16 services for the 2013-2015 Medicare Physician Payment Schedules. The RUC removed one service from the screen and will review one service once new codes go into effect and additional data are available. Utilization over 250,000 In April 2013, the RUC lowered the threshold to the CMS/Other source codes with Medicare utilization of 250,000 or more, which resulted in 26 services and was expanded to 52 services to include the family of services. The CPT Editorial Panel deleted 11 codes identified under this screen. The RUC removed nine services and submitted 32 recommendations to CMS for the 2015-2019 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. Utilization over 100,000 In October 2016, the RUC lowered the threshold to the CMS/Other source codes with Medicare utilization of 100,000 or more, which resulted in 27 services and was expanded to 41 services to include the family of services. The RUC referred two codes to CPT for deletion and submitted recommendations for 39 services for the 2019 Medicare Physician Payment Schedule. The RUC completed review of services under this screen. Utilization over 30,000 In October 2017, the RUC lowered the threshold to the CMS/Other source codes with Medicare utilization of 30,000 or more, which resulted in 34 services and was expanded to 55 services to include the family of services. The CPT Editorial Panel deleted 10 codes. The submitted recommendations for 45 services for the 2019-2020 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. In October 2018, the RUC reran this screen for CMS/Other source codes with 2017e Medicare utilization over 30,000, which resulted in seven services and expanded to 15 services. The RUC referred one code to the CPT Editorial Panel for revision and the CPT Editorial Panel deleted another code. The RUC submitted recommendations for 13 services for the 2020-21 Medicare Physician Payment Schedules.


Utilization over 20,000 In October 2019, the RUC lowered the threshold for this screen of CMS/Other source codes with 2018e Medicare utilization over 20,000, which resulted in nine services and expanded to 10 to include the family of services. The RUC referred three codes to the CPT Editorial Panel for revision. CPT deleted two codes. The RUC removed one service from this screen and will review one service after additional utilization data is available. The RUC submitted recommendations for three services for the 2021 Medicare Physician Payment Schedule. Bundled CPT® Services Reported 95% or More Together The Relativity Assessment Workgroup solicited data from CMS regarding services inherently performed by the same physician on the same date of service (95% of the time) in an attempt to identify pairings of services that should be bundled together. The CPT® Editorial Panel deleted 31 individual component codes and replaced them with 53 new codes that describe bundles of services. The RUC then surveyed and reviewed work and practice costs associated with these services to account for any efficiencies achieved through the bundling. The RUC completed review of all services under this screen. Reported 75% or More Together In February 2010, the Workgroup continued review of services provided on the same day by the same provider, this time lowering the threshold to 75% or more together. The Relativity Assessment Workgroup again analyzed the Medicare claims data and found 151 code pairs which met the threshold. The Workgroup then collected these code pairs into similar “groups” to ensure that the entire family of services would be coordinated under one code bundling proposal. The grouping effort resulted in 20 code groups, totaling 80 codes, and were sent to specialty societies to solicit action plans for consideration at the April 2010 RUC meeting. Resulting from the Relativity Assessment Workgroup review, 81 additional codes were added for review as part of the family of services to ensure duplication of work and practice expense was mitigated throughout the entire set of services. Of the 161 total codes under review, the CPT® Editorial Panel deleted 35 individual component codes and replaced the component coding with 126 new and/or revised codes that described the bundles of services. The RUC will review two services after additional utilization data is available. In August 2011, the Joint CPT®/RUC Workgroup on Codes Reported Together Frequently reconvened to perform its third cycle of analysis of code pairs reported together with 75% or greater frequency. The Workgroup reviewed 30 code pair groups and recommended code bundling for 64 individual codes. In October 2012, the CPT® Editorial Panel started the review of code bundling solutions. Of the 153 total codes under review, the CPT® Editorial Panel deleted 50 services. The RUC has submitted 103 code recommendations for the 2014-2019 Medicare Physician Payment Schedules. The RUC completed review of all services under this screen. In January and April 2015, the Joint CPT/RUC Workgroup on Codes Reported Together Frequently reconvened to perform its fourth cycle analysis of code pairs reported together with 75% or greater frequency. The Workgroup reviewed 8 code pair groups and recommended code bundling for 18 individual codes. In October 2015, the CPT Editorial Panel started review of the code bundling solutions. Of the 75 total codes under review, the CPT Editorial Panel deleted 26 services. The RUC submitted 47 code recommendations for the 2017-2019 Medicare Physician Payment Schedules and will review the two services after additional utilization data is available. In October 2017 the Relativity Assessment Workgroup performed the fifth cycle analysis of code pairs reported together with 75% or greater frequency. Only groups that totaled allowed charges of $5 million or more were included. As with previous iterations, any code pairs in which one of the codes was either


below 1,000 in Medicare claims data and/or contained at least one ZZZ global service were removed. Based on these criteria four groups or 8 codes were identified. The Relativity Assessment Workgroup determined two groups totaling four codes require code bundling solutions. Of the 12 total codes under review, the CPT Editorial Panel deleted one service. The RUC submitted 11 code recommendations for the 2020 and 2021 Medicare Physician Payment Schedules. The RUC completed review of all services under this screen. Low Value/Billed in Multiple Units CMS has requested that services with low work RVUs that are commonly billed with multiple units in a single encounter be reviewed. CMS identified services that are reported in multiples of five or more per day, with work RVUs of less than or equal to 0.50 RVUs. In October 2010, the Workgroup reviewed 12 CMS identified services and determined that six of the codes were improperly identified as the services were either not reported in multiple units or were reported in a few units and that was considered in the original valuation. The RUC submitted recommendations for the remaining six services for the 2012 Medicare Physician Payment Schedule. The RUC completed review of services under this screen. Low Value/High Volume Codes CMS has requested that services with low work RVUs and high utilization be reviewed. CMS has requested that the RUC review 24 services that have low work RVUs (less than or equal to 0.25) and high utilization. The RUC questioned the criteria CMS used to identify these services as it appeared some codes were missing from the screen criteria indicated. The RUC identified codes with a work RVU ranging from 0.01 - 0.50 and Medicare utilization greater than one million. In February 2011, the RUC reviewed the codes identified by this criteria and added 5 codes, totaling 29. The RUC submitted 24 recommendations to CMS for the 2012 Medicare Physician Payment Schedule and five recommendations to CMS for the 2013 Medicare Physician Payment Schedule. The RUC completed review of services under this screen. Multi-Specialty Points of Comparison List CMS requested that services on the Multi-Specialty Points of Comparison (MPC) list should be reviewed. CMS prioritized the review of the MPC list to 33 codes, ranking the codes by allowed service units and charges based on CY 2009 claims data as well as those services reviewed by the RUC more than six years ago. The RUC expanded the list to 182 services to include additional codes as part of a family (over 100 of these codes are part of the review of GI endoscopy codes). The CPT® Editorial Panel deleted 25 codes. The RUC submitted recommendations for 157 codes for the 2012-2015 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. CMS High Expenditure Procedural Codes In the Proposed Rule for 2012, CMS requested that the RUC review a list of 70 high Medicare Physician Payment Schedule expenditure procedural codes representing services furnished by an array of specialties. CMS selected these codes since they have not been reviewed for at least 6 years, and in many cases the last review occurred more than 10 years ago. The RUC reviewed the 70 services identified and expanded the list to 145 services to include additional codes as part of the family. The CPT® Editorial Panel deleted 20 codes. The RUC submitted 125 recommendations to CMS for the 2013-2019 Medicare Physician Payment Schedules. The RUC completed review of services under the first iteration of this screen.


In the Final Rule for 2016, CMS requested that the RUC review a list of 103 high Medicare Physician Payment Schedule high expenditure services across specialties with Medicare allowed charges of $10 million or more. CMS identified the top 20 codes by specialty in terms of allowed charges, excluding 010 and 090-day global services, anesthesia and Evaluation and Management services and services reviewed since CY 2010. The RUC expanded the list of services to 238 services to include additional codes as part of the family. The CPT Editorial Panel deleted 30 codes. The RUC submitted 208 recommendations to CMS for the 2017-2019 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. Services with Stand-Alone PE Procedure Time In June 2012, CMS proposed adjustments to services with stand-alone procedure time assumptions used in developing non-facility PE RVUs. These assumptions are not based on physician time assumptions. CMS prioritized CPT® codes that have annual Medicare allowed charges of $100,000 or more, include direct equipment inputs that amount to $100 or more, and have PE procedure times greater than five minutes for review. The RUC reviewed 27 services identified through this screen and expanded to 29 services to include additional codes as part of the family. The CPT® Editorial Panel deleted 11 codes. The RUC submitted 18 recommendations for the 2014-2015 Medicare Physician Payment Schedules. The RUC completed review of services under this screen. Pre-Time Analysis In January 2014, the RUC reviewed codes that were RUC reviewed prior to April 2008, with pre-time greater than pre-time package 4 Facility - Difficult Patient/Difficult Procedure (63 minutes) for services with 2012 Medicare Utilization over 10,000. The screen identified 19 services with more pre-service time than the longest standardized pre-service package and was expanded to 24 to include additional codes as part of the family. The RUC reviewed these services and referred three services to the CPT® Editorial Panel for revision. The CPT Editorial Panel deleted one service and will review three services for CPT 2018. The RUC reviewed 18 services and noted that they were all originally valued by magnitude estimation and therefore readjustments in pre-service time categories did not alter the work values. Additionally, crosswalk references for each service were presented validating the pre-time adjustments. The RUC noted that this screen was useful, however did not reveal any large outliers and therefore the utilization threshold does not need to be lowered to identify more services. The RUC submitted 20 recommendations for the 2016 Medicare Physician Payment Schedule. The RUC completed review of services under this screen. Post-Operative Visits 010-Day Global Codes In January 2014, the RUC reviewed all 477, 010-day global codes to determine any outliers. Many 010-day global period services only include one post-operative office visit. The Relativity Assessment Workgroup pared down the list to 19 services with >1.5 office visits and 2012 Medicare utilization > 1,000. The RUC reviewed the 19 services, which was expanded to 21 services for additional codes in the family of services, identified via this screen. The RUC referred two codes to the CPT Editorial Panel for revision. The RUC submitted recommendations for 21 services for the 2015-2017 Medicare Physician Payment Schedule. The RUC has completed review of the services under this screen. In October 2019, the identified five 010-day global period services more than one office visit based on 2018e Medicare utilization over 1,000. The RUC submitted three recommendations for the 2021 Medicare Physician Payment Schedule and will submit the remaining two for the 2022 Medicare Physician Payment Schedule.


090-Day Global Codes In January 2014, the RUC reviewed all 3,788, 090-day global codes to determine any outliers. Based on 2012 Medicare utilization data, 10 services were identified, that were reported at least 1,000 times per year and included more than six office visits. The RUC expanded the services identified in this screen to 38 to include additional codes as part of the family. The CPT® Editorial Panel deleted 8 services. The RUC submitted recommendations for 30 services for the 2015-2017 Medicare Physician Payment Schedule. The RUC has completed review of the services under this screen. In October 2019, the identified three 090-day global period services more than six office visits based on 2018e Medicare utilization over 1,000. The RUC submitted recommendations for these three services for the 2021 Medicare Physician Payment Schedule. The RUC has completed review of the services under this screen. High Level E/M in Global Period In October 2015, the RUC reviewed all services with Medicare utilization greater than 10,000 that have a level 4 (99214) or level 5 (99215) office visit included in the global period. There were no codes with volume greater than 10,000 that had a level 5 office visits included. Seven services were identified that have a level 4 office visit included. The RUC expanded the list of services to 11 services to include additional codes as part of the family. The RUC confirmed that the level 4 post-operative visits were appropriate and well-defined for four services. The CPT Editorial Panel deleted one code. The RUC submitted recommendations for 10 services for the 2017-2018 Medicare Physician Payment Schedules. The RUC noted that this screen will be complete after these services are reviewed because the RUC has more rigorously questioned level 4 office visits in the global period in recent years and will continue this process going forward. The RUC has completed review of the services under this screen. 000-Day Global Services Reported with an E/M with Modifier 25 In the NPRM for 2017 CMS identified 83 services with a 000-day global period billed with an E/M 50 percent of the time or more, on the same day of service, same patient, by the same physician, that have not been reviewed in the last five years with Medicare utilization greater than 20,000. The RUC commented that it appreciated CMS’ identification of an objective screen and reasonable query. However, based on further analysis of the codes identified, it appears only 19 services met the criteria for this screen and have not been reviewed to specifically address an E/M performed on the same date. There were 38 codes that did not meet the screen criteria; they were either reviewed in the last 5 years and/or are not typically reported with an E/M. For 26 codes, the summary of recommendation (SOR), RUC rationale or practice expense inputs submitted specifically states that an E/M is typically reported with these services and the RUC accounted for this in its valuation. The RUC requested that CMS remove 64 services that did not meet the screen criteria or which have already been valued as typically being reported with an E/M service. The RUC requested that CMS condense and finalize the list of services for this screen to the 19 remaining services. In the Final Rule for 2017, CMS did finalize the list of 000-day global services reported with an E/M to the 19 services that truly met the criteria. The RUC recommended that two additional codes be removed from this screen as the specialty societies discovered that in fact an E/M as typical was considered in the survey process. Additional codes were added as part of the family of codes identified, totaling 22. The CPT Editorial Panel deleted one code and the RUC submitted 21 recommendations for the 2019 Medicare Physician Payment Schedule. The RUC has completed review of the services under this screen.


Negative IWPUT In October 2017, the RUC identified 22 services with a negative IWPUT and Medicare utilization over 10,000 for all services or over 1,000 for Harvard valued and CMS/Other source codes. The RUC expanded the services identified in this screen to 56 services to include additional codes as part of the family. The CPT Editorial Panel deleted 15 services. The RUC submitted 41 recommendations for the 2019-2020 Medicare Physician Payment Schedules. The RUC has completed review of the services under this screen. Contractor Priced with High Volume In April 2018, the RUC identified five contractor-priced Category I CPT codes that have 2017 estimated Medicare utilization over 10,000. The RUC expanded the services identified in this screen to seven to include additional codes as part of a family. The RUC referred two codes to the CPT Editorial Panel for deletion. The RUC submitted four recommendations for the 2020-2021 Medicare Physician Payment Schedule. The RUC will review the remaining service after two years of additional data is available. CPT Modifier -51 Exempt List In April 2018, the RUC identified seven services on the CPT Modifier -51 Multiple Procedures exempt list with 2017 estimated Medicare utilization over 10,000. The RUC examined the data provided on the percentage reported alone, physician pre and intra time and determined that this is an appropriate screen. The RUC recommended that four services be removed from the Modifier -51 exempt list and that three services remain on the list as they are separate and distinct services. The RUC notes that the CPT Editorial Panel will be reexamining this list in February 2019. The RUC has completed review of the services under this screen. Public Comment Requests In 2011, CMS announced that due to the ongoing identification of potentially misvalued services by CMS and the RUC, the Agency will no longer conduct a separate Five-Year Review. CMS will now call for public comments on an annual basis as part of the comment process on the Final Rule each year. Final Rule for 2013 In the Final Rule for the 2013 Medicare Physician Payment Schedule, the public and CMS identified 35 potentially misvalued services, which was expanded to 39 services to include the entire code family. The RUC reviewed these services and recommended that eight services be removed from review as two G-codes lacked specialty society interest and six services are not potentially misvalued since there is no reliable way to determine an incremental difference from open thoracotomy to thorascopic procedures. The CPT Editorial Panel deleted two services. The RUC submitted recommendations for 29 services for the 2014-2019 Medicare Physician Payment Schedules. The RUC has completed review of the services under this screen. Final Rule for 2014 CMS did not receive any publicly nominated potentially misvalued codes for inclusion in the Proposed Rule for 2014. To broaden participation in the process of identifying potentially misvalued codes, CMS sought the input of Medicare contractor medical directors (CMDs). The CMDs have identified over a dozen services which CMS is proposing as potentially misvalued. The RUC reviewed these services and appropriate families, totaling 90 services. The CPT® Editorial Panel deleted 11 services. The RUC submitted recommendations to CMS for 79 services for the 2015-2018 Medicare Physician Payment Schedules. The RUC has completed review of the services under this screen. Final Rule for 2015 In the Final Rule for 2015 the public and CMS nominated 26 services as potentially misvalued, which the RUC expanded to 53 services to include additional codes as part of this family. The CPT Editorial Panel


deleted 16 services. The RUC submitted 37 recommendations for the 2016-2019 Medicare Physician Payment Schedules. The RUC has completed review of the services under this screen. Final Rule for 2016 In the Final Rule for 2016 the public and CMS nominated 25 services as potentially misvalued, which the RUC expanded to 53 services to include an additional code as part of the family. The CPT Editorial Panel deleted eight services. The RUC submitted 45 recommendations for the 2017-2019 Medicare Physician Payment Schedules. The RUC has completed review of the services under this screen. Final Rule for 2017 In the Final Rule for 2017 there were no public nominations for services in which the RUC was not already addressing. Final Rule for 2018 In the Final Rule for 2018 the public and CMS nominated six services as potentially misvalued, which the RUC expanded to nine services. The RUC submitted nine recommendations for the 2019-2020 Medicare Physician Payment Schedules. The RUC has completed review of the services under this screen. Final Rule for 2019 In the Final Rule for 2019 the public and CMS nominated nine services as potentially misvalued, which was expanded to 12 services as part of the family. The CPT Editorial Panel deleted two services. The RUC will submit 10 recommendations for the 2021 Medicare Physician Payment Schedule. The RUC has completed review of the services under this screen. Work Neutrality For every CPT code recommendation and family, the RUC submits utilization assumptions based on the specialty societies estimate for the next year of Medicare utilization. Starting with CPT 2009, the Relativity Assessment Workgroup began assessing all services for work neutrality. In 2012, the RUC confirmed that the RUC and specialty societies work neutrality calculation expectation is a zero change target. However, if actual work RVUs turn out to be 10% or greater than the former work RVUs for the family, the family should undergo review by the Relativity Assessment Workgroup. Three code families have been identified for re-examination, one from CPT 2009, CPT 2011 and CPT 2012. Two families were determined to have correct utilization assumptions after re-evaluating the coding structure and initial assumptions. The CPT 2012 family went through revisions at the CPT Editorial Panel as well as extensive educational efforts were engaged. However, after continued examination this family will be resurveyed for the 2022 Medicare Physician Payment Schedule. Three additional code families were identified for re-examination from CPT 2018. One family appears to possibly be due to miscoding. All three families will be re-examined after additional utilization data are available. Other Issues In addition to the above screening criteria, the Relativity Assessment Workgroup performed an exhaustive search of the RUC database for services indicated by the RUC to be re-reviewed at a later date. Three codes were found that had not yet been re-reviewed. The RUC recommended a work RVU decrease for two codes and to maintain the work RVU for another code. CMS also identified 72 services that required further practice expense review. The RUC submitted practice expense recommendations on 67 services and the CPT® Editorial Panel deleted 5 services. The RUC also reviewed special requests for 19 audiology and speech-language pathology services. The RUC submitted recommendations for 10 services for the 2010 Medicare Physician Payment Schedule and the remaining nine services for the 2011 Medicare Physician Payment Schedule.


CMS Requests and RUC Relativity Assessment Workgroup Code Status Total Number of Codes Identified* 2,545 Codes Completed 2,456 Work and PE Maintained 662 Work Increased 306 Work Decreased 844 Direct Practice Expense Revised (beyond work changes) 181 Deleted from CPT® 463 Codes Under Review 89 Referred to CPT® Editorial Panel or CPT Assistant 54 RUC to Review for CPT 2022 16 RUC to review future review after additional data obtained 19 *The total number of codes identified will not equal the number of codes from each screen as some codes have been identified in more than one screen. The RUC’s efforts for 2009-2020 have resulted in more than $5 billion in annual redistribution within the Medicare Physician Payment Schedule.

All 2018 Medicare Claims from: Texas – locality 18 Place of Service – Independent Clinic (Medicare Place of Service Code 49) Specialty – Pediatrics (Medicare Specialty Code 37)

CPT Code Short Descriptor

Medicare Place of Service Code

Medicare Specialty Code State

Medicare Locality

2018 Medicare Utilization

2018 Medicare Payment

99489 CMPLX CHRON CARE ADDL 30 MI 49 – Independent Clinic 37 - Pediatrics TX 18 68,487 $ 2,489,005

99492 1ST PSYC COLLAB CARE MGMT 49 – Independent Clinic 37 - Pediatrics TX 18 6,650 $ 825,887

99494 1ST/SBSQ PSYC COLLAB CARE 49 – Independent Clinic 37 - Pediatrics TX 18 13,518 $ 693,773

99487 CMPLX CHRON CARE W/O PT VSI 49 – Independent Clinic 37 - Pediatrics TX 18 6,992 $ 509,680

99493 SBSQ PSYC COLLAB CARE MGMT 49 – Independent Clinic 37 - Pediatrics TX 18 43 $ 4,270

99203 OFFICE/OUTPATIENT VISIT NEW 49 – Independent Clinic 37 - Pediatrics TX 18 32 $ 2,218

99358 PROLONG SERVICE W/O CONTACT 49 – Independent Clinic 37 - Pediatrics TX 18 8 $ 614

99359 PROLONG SERV W/O CONTACT AD 49 – Independent Clinic 37 - Pediatrics TX 18 14 $ 591

99484 CARE MGMT SVC BHVL HLTH CON 49 – Independent Clinic 37 - Pediatrics TX 18 2 $ 75

99091 COLLJ & INTERPJ DATA EA 30 49 – Independent Clinic 37 - Pediatrics TX 18 1 $ 45

99484 CARE MGMT SVC BHVL HLTH CON 49 – Independent Clinic 37 - Pediatrics TX 18 1 $ 37

99205 OFFICE/OUTPATIENT VISIT NEW 49 – Independent Clinic 37 - Pediatrics TX 18 1 $ 15

Total 2018 Medicare Payment: $ 4,526,210

CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association.

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AMA/Specialty Society RVS Update Committee Summary of Recommendations

October 2009

Immunization Administration

The CPT Editorial Panel revised the reporting of immunization administration in the pediatric population in order to better align the service with the evolving best practice model of delivering combination vaccines. This revision in the reporting of immunization administration will then permit a more accurate reflection of the physician work involved, reducing barriers to the spread of technology and allowing positive change in the practice of medicine. The CPT nomenclature needs to be kept up-to-date with the reporting of services associated with vaccine delivery, which has changed due to the licensure of additional combination vaccines as well as those with more components. The two new immunization administration codes will more accurately reflect the service as currently delivered. The specialty society presented compelling evidence that the physician time has changed in performing these services by providing rationale for an increasing frequency of counseling necessary to convince parents to 1) immunize their children at all; and 2) to persuade them of the safety and efficacy of component vaccines. Increased attention to vaccine safety on the Internet and in other media has driven anxiety and have necessitated additional physician involvement and discussion with parents. The RUC agreed that this increased physician work should be recognized. The specialty society presented that the typical patient receives two vaccinations in one visit. However, based upon the age of the patient and specific vaccines available, some visits require only 90460, some visits require one or more units of 90460 and one or more units of 90461. It was noted that higher multiples of reporting of these codes would occur at infrequent visits (primarily 2 month, 6 months, and 4 years of age) and any payor concern regarding coding and valuation with these outlier visits may be addressed with a limit on the number of 90461 units allowed.


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90460 Immunization Administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profession; first vaccine/toxoid component The RUC recommends that the survey intra-service time of 7 minutes should be reflected as the total time. Pre-service time, as described in the original SOR, is described in the preventive medicine services and the post-service descriptions reflect activities performed by clinical staff. The RUC agreed that the valuation for this service falls between the range of a 99211 (Work RVU=0.17) and the survey median of 0.25, and determined that considering that more than one unit is often coded, a value of 0.20 would be appropriate. 99401 Preventive Counseling, 15 minutes (work RVU = 0.48) is a reasonable comparison. Using the ratio of time of 7 minutes/15 minutes, a value of 0.20 is reasonable. In addition, the committee considered that they typical patient may receive two units of this service 0.40 total with 14 minutes of counseling, which is comparable to a 99212 (work RVU = 0.48 and 16 minutes of total time). The RUC recommends a work value of 0.20 and physician intra-service time of 7 minutes for 90460. 90461 – Immunization Administration through 18 years of age via any route of administration, with counseling by physician or other qualified health profession; each additional vaccine/toxoid component (List separately in addition to code for primary procedure) The RUC understands that additional counseling is required to describe the additional vaccines and to address concern related to media reports of component vaccines. The survey indicated that this additional counseling requires 5 minutes of physician time. The RUC determined that the survey’s 25th percentile work RVU of 0.16 is appropriate and reflects a proper rank order relationship with 99401 Preventive Counseling as described above and also in relationship to other counseling services, such as 99407 Smoking Cessation (5/15 or 1/3 of 0.50). The RUC recommends a work value of 0.16 and a physician intra-service time of 5 minutes for 90461. Practice Expense – The RUC recommends the direct expense inputs of18 minutes clinical staff time, supplies and equipment for 90460 and no direct inputs for 90461 The individual inputs are described in the attached handout. PLI Crosswalk – The new codes could be crosswalked to the existing immunization and administration codes, 90471 and 90472.


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CPT Code (•New)

Tracking

Num-ber

CPT Descriptor Global Period

Work RVU Recommen-dation

Codes 90465-490460 and 90461 must be reported in addition to the vaccine and toxoid code(s) 90476-90749. Report codes 90460 and 90461 only when the physician or qualified health care professional provides face-to-face counseling of the patient and family during the administration of a vaccine. For immunization administration of any vaccine that is not accompanied by face-to-face physician or qualified health care professional counseling to the patient/family or for administration of vaccines to patients over 18 years of age, report codes 90471-90474. If a significant separately identifiable Evaluation and Management service (eg, office or other outpatient services, preventive medicine services) is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes. A component refers to all antigens in a vaccine that prevent disease(s) caused by one organism (see codes 90460 and 90461). Combination vaccines are those vaccines that contain multiple vaccine components. (For allergy testing, see 95004 et seq) (For skin testing of bacterial, viral, fungal extracts, see 86485-86580) (90465-90468 have been deleted. To report, see 90460, 90461) D 90465 Immunization administration under 8 years of age (includes percutaneous,

intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day (Do not report 90465 in conjunction with 90467)

XXX N/A

D +90466 Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; each additional injection (single or combination vaccine/toxoid), per day

ZZZ N/A


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CPT Code (•New)

Tracking

Num-ber

CPT Descriptor Global Period

Work RVU Recommen-dation

(List separately in addition to code for primary procedure) (Use 90466 in conjunction with 90456 or 90467)

D 90467 Immunization administration under age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day (Do not report 90467 in conjunction with 90465)

XXX N/A

D +90468 Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician counsels the patient/family; each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for (Use 90468 in conjunction with 90465 or 90467)

ZZZ N/A

90460 E1 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component

XXX 0.20

90461 E2 each additional vaccine/toxoid component (List separately in addition to code for primary procedure)

(Use 90460 for each vaccine administered. For vaccines with multiple components [combination vaccines], report 90460 in conjunction with 90461 for each additional component in a given vaccine) (For therapeutic or diagnostic injections, see 96372-96379) (90465-90468 have been deleted. To report, see 90460, 90461)

ZZZ 0.16

CPT Code: 90460 AMA/SPECIALTY SOCIETY RVS UPDATE PROCESS SUMMARY OF RECOMMENDATION CPT Code:90460 Tracking Number E1 Specialty Society Recommended RVU: 0.25 Global Period: XXX RUC Recommended RVU: 0.20 CPT Descriptor: Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component CLINICAL DESCRIPTION OF SERVICE: Vignette Used in Survey: A 15-year-old patient receives the Human Papilloma virus (HPV) vaccine from her physician. The ordering physician discusses the risks of the vaccine and the disease for which it provides protection. The parent/guardian is given the CDC vaccine information statement (VIS). The parent/guardian consents and the nurse prepares the vaccine. The patient receives the vaccine by a single injection, and the nurse charts the required information and accesses and enters the vaccine data into the statewide immunization registry. The patient is discharged home after the nurse confirms that there are no serious immediate reactions. Percentage of Survey Respondents who found Vignette to be Typical: 95% Site of Service (Complete for 010 and 090 Globals Only) Percent of survey respondents who stated they perform the procedure; In the hospital 0% , In the ASC 0%, In the office 0% Percent of survey respondents who stated they typically perform this procedure in the hospital, stated the patient is; Discharged the same day 0% , Kept overnight (less than 24 hours) 0% , Admitted (more than 24 hours) 0% Percent of survey respondents who stated that if the patient is typically kept overnight also stated that they perform an E&M service later on the same day 0% Moderate Sedation Is moderate sedation inherent to this procedure in the Hospital/ASC setting? No Percent of survey respondents who stated moderate sedation is typical in the Hospital/ASC setting? 0% Is moderate sedation inherent to this procedure in the office setting? No Percent of survey respondents who stated moderate sedation is typical in the office setting? 0% Is moderate sedation inherent in your reference code (Office setting)? No Is moderate sedation inherent in your reference code (Hospital/ASC setting)? No Description of Pre-Service Work: Description of Intra-Service Work: The physician discusses the specific risks/benefits of the first vaccine component including the risks associated with this component and the risk of not receiving it to include both health risk from the preventable disease and the social concerns related to school mandates for vaccines. The physician then discusses the benefit of being immunized for this disease. The parent ‘s questions regarding the safety of the inactive ingredients in the vaccine such as preservatives and the likelihood of this vaccine causing injury, including brain damage, and/or the disease for which it is providing protection against are addressed. After further discussion, the parent then agrees with need for immunization. The physician then discusses the care plan for the child in the days to follow specific to the anticipated or possible side effects of the first vaccine component: soreness and pain at the injection site, fever, and other side effects. The physician reviews the signs or symptoms that warrant a call back. Description of Post-Service Work:

CPT Code: 90460 SURVEY DATA RUC Meeting Date (mm/yyyy) 10/2009 Presenter(s): Steve Krug, MD, FAAP and Margie Andreae, MD, FAAP Specialty(s): American Academy of Pediatrics (AAP) CPT Code: 90460

Sample Size: 786 Resp N: 87 Response: 11.0 %

Sample Type: Panel Additional Sample Information: Sample drawn from membership of the AAP Section on Administration & Practice Management Low 25th pctl Median* 75th pctl High

Service Performance Rate 0.00 250.00 800.00 1350.00 5000.00 Survey RVW: 0.15 0.25 0.25 0.39 0.75 Pre-Service Evaluation Time: 3.00 Pre-Service Positioning Time: 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 Intra-Service Time: 0.00 5.00 7.00 8.00 20.00 Immediate Post Service-Time: 2.00

Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.00 99239x 0.00 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 **Physician standard total minutes per E/M visit: 99291 (70); 99292 (30); 99231 (20); 99232 (40); 99233 (55); 99238(38); 99239 (55); 99211 (7); 99212 (16); 99213 (23); 99214 (40); 99215 (55); 99354 (60); 99355 (30); 99356 (60); 99357 (30) Specialty Society Recommended Data Please, pick the pre-service time package that best corresponds to the data which was collected in the survey process: XXX Global Code CPT Code: 90460 Recommended Physician Work RVU: 0.20

Specialty

Recommended Pre-Service Time

Specialty Recommended

Pre Time Package Adjustments to

Pre-Service Time

Pre-Service Evaluation Time: 0.00 0.00 0.00 Pre-Service Positioning Time: 0.00 0.00 0.00 Pre-Service Scrub, Dress, Wait Time: 0.00 0.00 0.00 Intra-Service Time: 7.00

Immediate Post Service-Time: 0.00

Post Operative Visits Total Min** CPT Code and Number of Visits Critical Care time/visit(s): 0.00 99291x 0.00 99292x 0.00 Other Hospital time/visit(s): 0.00 99231x 0.00 99232x 0.00 99233x 0.00 Discharge Day Mgmt: 0.00 99238x 0.0 99239x 0.0 Office time/visit(s): 0.00 99211x 0.00 12x 0.00 13x 0.00 14x 0.00 15x 0.00 Prolonged Services: 0.00 99354x 0.00 55x 0.00 56x 0.00 57x 0.00 Modifier -51 Exempt Status

CPT Code: 90460 Is the recommended value for the new/revised procedure based on its modifier -51 exempt status? No New Technology/Service: Is this new/revised procedure considered to be a new technology or service? No KEY REFERENCE SERVICE: Key CPT Code Global Work RVU Time Source 99441 XXX 0.25 RUC Time CPT Descriptor Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion KEY MPC COMPARISON CODES: Compare the surveyed code to codes on the RUC’s MPC List. Reference codes from the MPC list should be chosen, if appropriate that have relative values higher and lower than the requested relative values for the code under review. Most Recent MPC CPT Code 1 Global Work RVU Time Source Medicare Utilization 94010 XXX 0.17 RUC Time 1,242,167 CPT Descriptor 1 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation Most Recent MPC CPT Code 2 Global Work RVU Time Source Medicare Utilization 36405 XXX 0.31 RUC Time 14 CPT Descriptor 2 Venipuncture, younger than age 3 years, necessitating physician's skill, not to be used for routine venipuncture; scalp vein Other Reference CPT Code Global Work RVU Time Source 99406 XXX 0.24 RUC Time CPT Descriptor Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes RELATIONSHIP OF CODE BEING REVIEWED TO KEY REFERENCE SERVICE(S): Compare the pre-, intra-, and post-service time (by the median) and the intensity factors (by the mean) of the service you are rating to the key reference services listed above. Make certain that you are including existing time data (RUC if available, Harvard if no RUC time available) for the reference code listed below. Number of respondents who choose Key Reference Code: 39 % of respondents: 44.8 % TIME ESTIMATES (Median)

CPT Code: 90460

Key Reference CPT Code:

99441

Source of Time RUC Time

Median Pre-Service Time 0.00 1.00 Median Intra-Service Time 7.00 8.00 Median Immediate Post-service Time 0.00 4.00

Median Critical Care Time 0.0 0.00

Median Other Hospital Visit Time 0.0 0.00

Median Discharge Day Management Time 0.0 0.00

Median Office Visit Time 0.0 0.00

Prolonged Services Time 0.0 0.00

Median Total Time 7.00 13.00

CPT Code: 90460 Other time if appropriate INTENSITY/COMPLEXITY MEASURES (Mean)

(of those that selected Key Reference code)

Mental Effort and Judgment (Mean)

The number of possible diagnosis and/or the number of management options that must be considered

2.26 2.41

The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be reviewed and analyzed

3.59 2.85

Urgency of medical decision making 2.74 3.05

Technical Skill/Physical Effort (Mean)

Technical skill required 1.49 1.51

Physical effort required 1.31 1.31

Psychological Stress (Mean)

The risk of significant complications, morbidity and/or mortality 3.46 2.97

Outcome depends on the skill and judgment of physician 2.64 2.95

Estimated risk of malpractice suit with poor outcome 4.31 3.03

INTENSITY/COMPLEXITY MEASURES CPT Code Reference Service 1

Time Segments (Mean)

Pre-Service intensity/complexity 1.44 1.31

Intra-Service intensity/complexity 3.69 3.03

Post-Service intensity/complexity 1.90 1.92

Additional Rationale and Comments Describe the process by which your specialty society reached your final recommendation. If your society has used an IWPUT analysis, please refer to the Instructions for Specialty Societies Developing Work Rela

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